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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4473_Библиотеки_им_академика_М_И_Перельмана
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344
Right Acoustic Rhinometry
Left
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G. H. Mlynski et al.
before after
Decongestant
MCA0
Area [cm2]
1,22 1,13
0,37 0,37
Distance [cm]
MCA1
Area [cm2]
0,42 0,50
2,60 2,26
Distance [cm]
MCA2
Area [cm2]
1,95 --
5,17 --
Distance [cm]
Vol 1 (0 - 5 cm) [cm
5,67 6,55
Vol 2 (2 cm - 5 cm) [cm
3,10 4,06
Diffuser Opening Angle [°]
10,73 10,95
3
]
3
]
before decong. after decong. before decong. after decong.
[cm]
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
-1.0
5.0 4.0 3.0 2.0 1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0
6.0
MCA1
MCA0
MCA2
Fig. 27.8 Illustration of acoustic rhinometric assessment including numerical values
In Fig.27.8 the ARM examination of the same
patient as in Fig.27.5 is illustrated. As a diagnosis at rst glance on the right nasal side it is
possible.
the pathologically low resistance on the left side
are normalized.
It is not necessary to increase the stiffness of
the right nasal wing to correct the pathological
valve collapse, caused by a strong Bernoulli phe-
• To identify the localization of the skeletal stenosis as aetiology for the pathological resistance after decongestion (cf. Fig.27.8 in the
area of MCA1).
• On the right nasal side the narrow entrance of
the diffuser (MCA1) before and after decongestion is the cause for the pathologically
increased turbulence behaviour (cf. Fig.27.8).
• The narrow MCA1 causes a high local airow
velocity and thereby a strong Bernoulli effect
in the area of the internal nasal valve.
• On the left nasal side a marked increase of the
cross-sectional area in the diffuser causes a
turbulence, which is on the border to pathological nding (cf. Fig.27.8).
nomenon due to a high local air ow velocity
within the narrow MCA1 (see Sect. 20.2). After
correcting the constriction, physiological function of the nasal valve is to be expected. The
pathological turbulence behaviour is also
improved if the entry area of the diffuser (MCA1)
becomes larger.
A reduction of the turbinates is contraindicated, because the already large opening angle of
the diffuser would result in a further increase of
endonasal turbulence. The marginal turbulence
behaviour on the left nasal side will be improved
by straightening of the nasal septum because the
nozzle effect of the vestibule is regained by normalization of the MCA1.
The postoperative result 1 year after surgery is
Information obtained by RRM and ARM are
presented in Sect. 27.3.2.2 and Fig.27.14b.
helpful in the preoperative planning of rhinosurgical steps.
In case of the patient with the diagnostic RRM
27.2.3 Long-Term Rhinometry (LRM)
and ARM ndings in Figs.27.5 and 27.7, the sur-
gical aim is to increase the width on the right
nasal side by septoplasty. Thereby, the pathologically increased resistance on the right side and
LRM was developed because RMM, RRM and
ARM only allow an assessment of nasal obstruction at the time of the measurement [47].
before after
0,91 0,92
0,37 0,37
0,91 1,00
2,26 1,92
1,49 3,38
4,49 4,49
Vol 1 (0 - 5 cm) [cm
7,01 11,18
Vol 2 (2 cm - 5 cm) [cm
4,18 8,37
Diffuser Opening Angle [°]
4,83 11,64
2
[cm
]
Decongestant
MCA0
Area [cm2]
Distance [cm]
MCA1
Area [cm2]
Distance [cm]
MCA2
Area [cm2]
Distance [cm]
3
]
3
]
27 New Measurement Methods intheDiagnostic ofNasal Obstruction
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during inspiration separately for each side of the
nose in relation to time. The lower graph shows
the heart rate for estimating physical activity,
respiratory rate, as well as nasal minute volume
(NMV) in relation to time.
27.2.3.1 Upper Graph (Figs.27.10
The curves for the nasal ow allow a visual
assessment of the nasal cycle at a glance. At
physical rest or light physical activity, a “classical type” of nasal cycle should occur, with
reciprocal alternations between the two sides
of the nose in working and resting phases. With
increasing physical activity, the simultaneous
transition of both sides of the nose into working and resting phases (the “In-concert” type)
is a physiological response to increased oxygen demand (see Chap. 20). In this situation,
the nasal ow in both sides should reach
between 250 and 500 mL/s, as shown in
Fig. 27.10. These ow velocities cannot be
reached in the presence of pathological nasal
air resistance with the deployment of mouthbypass breathing. An example is shown in
Fig.27.11.
345
and27.11)
Fig. 27.9 Measurement system for long-term
rhinoowmetry
However, some patients complain about symptoms that occur at other times of the day. LRM
makes it possible to measure nasal ow separately for each side of the nose, along with the
heart rate to serve as an index for physical activity over a 24-h time period under the patient’s
everyday life conditions. Nasal ow is measured
using standard commercial nasal oxygen cannulas and the heart rate using standard ECG electrodes. Recording and storing is performed by
means of a battery-powered portable device
(Fig. 27.9). The recording of the nasal cycle
enhance the facilities to objectify the nasal respiratory function [48].
Figure 27.10 illustrates the graphical curves
resulting from a LRM examination. The upper
graph presents the maximal nasal ow values
27.2.3.2 Lower Graph (Figs.27.10
and27.11)
Heart Rate (Orange Curve)
In LRM, the heart rate is used to determine the
level of physical activity. This relationship is
known from physiology (Table 27.6). Please
note that these values can vary considerably
between people, depending on age, gender, level
of education and also on medication (e.g. beta
blockers). Therefore, these values can only be
used relatively.
Since the oxygen requirement depends on
physical activity, the heart rate provides an
information of the oxygen requirement and thus
the necessary respiratory ow. The heart rate is
therefore an important measure when assessing
the curves for ow, breathing rate and nasal
breathing minute volume.
346
11:00 13:00
15:00 17:00 19:00 21:00 23:00 1:00 3:00 5:00 7:00 9:00
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Flow left [ml/s]Flow right [ml/s]
Flow
800
600
400
200
0
12 :00
HR [1/min] BR [1/min] NMV [L/min]
HR
120
100
80
60
40
physical activity
12 :0014:0016:00 18:0020:00 22:00 0:002:00 4:006:00 8:0010:00
16 :0018:0020:00 22:00 0:00 2:00 4:006:00 8:0010:00
14 :00
Moderate
Slight
physical activity
Classic typeIn- concert type
Physical rest (sleep)
G. H. Mlynski et al.
Flow
800
600
400
200
0
BR
NMV
40
30
20
10
0
Fig. 27.10 Findings from LRM in a person with normal
nasal breathing. To better grasp the relation between physical activity and mucosal congestion in the nose, in this
gure the type of cycle and the amount of physical activity
graph, nasal respiratory velocity at maximal inspiration in
mL/s (red right nose, blue, left nose). Lower graph:
orange, heart rate (HR); green, nasal respiratory minute
volume (NMV) in L/min; purple, respiratory rate (BR)
were marked. x-axis: time of day in hours. y-axis: upper
Flow left [ml/s]Flow right [ml/s]
Flow
800
600
400
200
0
11:00 13:00 15:00 17:00 19:00 21:00 23:00 1:00 3:00 5:00 7:00 9:00
HR [1/min] BR [1/min] NMV [L/min]
HR
120
100
80
60
40
Fig. 27.11 RRM, ARM, and LRM ndings in a patient without nasal obstruction
With sufcient nasal breathing, the minute volume and the heart rate should have a similar prole: with increasing activity, the nasal minute
volume also increases and vice versa. If, with
increasing physical activity, the nasal airow is no
longer sufcient for the current oxygen demand,
mouth-bypass breathing occurs. This can be recognized by a falling curve of the nasal respiratory
minute volume while the heart rate rises.
Breathing Rate (Purple Curve)
The breathing rate under resting conditions rate
is 12–16 breaths per minute.
The breathing rate curve provides an information of the effectiveness of the patient’s breathing
technique. In conditions of increased oxygen
demand under physical stress, there are two
breathing techniques available to increase the
minute volume:
Flow
800
600
400
200
0
NMV
BR
40
30
20
10
0
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347
Table 27.6 Heart rate as indicator of physical activity
Heart rate Physical activity
<80/min Physical rest
80–100/min Slight physical activity
>100–120/min Moderate physical activity
>120/min Severe physical activity
Table 27.7 Physiologic reference values of nasal respiratory minute volume during physical activity
Nasal respiratory minute
Physical activity
Physical rest At least 5L/min
Light physical activity At least 10L/min
Moderate physical
activity
Severe physical activity At least 30L/min
volume
At least 20L/min
• Increasing the respiratory rate with decreasing
tidal volume.
• Decreasing respiratory rate with increased
tidal volume. Due to the lower percentage of
dead-space ventilation, the latter technique is
more effective.
Nasal Minute Volume (NMV) (Green Curve)
Nasal minute volume is the total volume of air
that is inhaled through both sides of the nose during 1 min. In combination with the physical
activity, one can use the reference values known
from physiology in Table27.7.
If the measured values for the nasal minute
volume fall below the indicated reference value
(as in Fig. 27.11), one can conclude that
mouth- bypass breathing is taking place. This
can be a sign of nasal obstruction [49].
Table27.8 provides an initial evaluation of the
obstruction.
Table 27.8 Estimation of nasal obstruction based on
onset of mouth breathing
Onset of mouth-bypass
breathing during
Physical rest Severe obstruction
Slight physical activity Moderate obstruction
Moderate physical activity Slight obstruction
Severe physical activity No obstruction
Extent of nasal
obstruction
lead to symptoms that occur at even normal or
slightly elevated levels of nasal airway resistance,
which the patient compensates by mouth-bypass
breathing. In such cases the LRM shows low levels of baseline nasal respiratory volume per minute that do not increase with increased physical
activity.
In diagnosing sicca symptoms and in evaluating the “empty nose syndrome” LRM can be a
valuable diagnostic tool. The complete absence of
resting phases suggests that either the nose is too
wide or that the congestive capacity of the nasal
mucosa has been so greatly reduced that closure
of the nose permitting a resting phase is no longer
possible. In such cases, LRM often shows only
minimal ventilation indicated by a very low nasal
minute volume, since these patients minimize
nasal airow by unconsciously switching over to
mouth-bypass breathing as a way to reduce
chronic dryness in their nose by minimizing nasal
airow. By this habit, they articially create resting phases for both nasal side by means of mouthbypass breathing. Such LRM ndings provide an
indication for the treatment option of surgically
reducing the nasal cavity width. If resting phases
can still be observed in the nasal cycle, this would
justify conservative therapy.
27.2.3.3 Indications forLong-Term
Rhinometry
LRM is not required for every patient with nasal
obstruction. It is indicated when the magnitude of
nasal obstruction determined by RMM or RRM
does not fully explain the patient’s symptoms.
Since nasal airway resistance accounts for about
60% of total airway resistance, a deciency in the
respiratory musculature or the cardiovascular
system or poor general physical condition may
27.3 Diagnostic Procedures
forObjectifying Nasal
Obstruction andIts Causes
27.3.1 Combination ofRRM, ARM
andLRM
With RRM, ARM and LRM different but
additional information about nasal obstructions can be obtained
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G. H. Mlynski et al.
• RRM provides uid dynamic information
about the extent of an obstruction (airway
resistance), about the effects of a narrowing
(hydraulic diameter) and about the turbulence
behaviour (ow at complete turbulence).
Measuring the inspiratory NVC can also estimate the nasal airway resistance due to the
Bernoulli phenomenon (ΔR).
• ARM provides insight into the geometry of
the inside of the nose up to a depth of 5cm
from the outer nasal ostium [50] and thus provides information about the structure of the
inner nose in the anterior region, which is
important for air dynamics with regard to stenoses and regulation the airow in the nasal
cycle (see Sect. 20.3).
• LRM provides information about the nasal
cycle as an important basis for the respiratory
function of the nose. We receive data with
which we can recognize the physiological process and the pathological disorders of the
nasal cycle under the daily living conditions of
the patient. The regulation of the nasal air ow
according to the oxygen demand during physical activity can be assessed in terms of
efciency.
The complementarity of these three meth-
ods leads to the conclusion that combining
them is useful for improving the diagnostic
evaluation of nasal obstruction. Every patient
complaining of nasal obstruction should
undergo a RRM and ARM. A supplemental
LRM should be performed:
• If the patient’s symptoms occur at times of
day or night other than the time of testing.
• If the endonasal ndings and results of
acoustic and rhinoresistometric testing cannot fully explain the symptoms reported by
the patient [48].
• If insight into the nasal cycle is necessary, e.g.
in the presence of unexplained uctuating
obstructions, for sicca symptoms and when
mouth breathing predominates despite only
minor nasal obstruction.
The extent and the causes of nasal obstruction
should be objectively determined according to the
algorithm presented in Fig. 27.12. The positive
impact of standardized decision making in rhinosurgery has recently been demonstrated [51].
27.3.2 Examples
In the following section, we will use clinical
examples to demonstrate how the combination of
RRM and ARM allows to diagnose the extent and
the cause of nasal obstruction. LRM will be additionally included in a few of the examples for
didactic purposes, even though it would only be
necessary for establishing the diagnosis in examples 6 and 7.
In describing the ndings, we will employ the
classication of regions in the nose recommended
by Cottle (1961) (Table27.9).
27.3.2.1 Example 1: No Nasal
Complaints
Patient: male, 20years of age
• History: No trauma recalled.
• Complaints: No rhinologic symptoms.
• Outer nose: Normal.
• Endonasal ndings: Slight septal deviation to
the right without any relevant stenosis.
Turbinates on the left swollen, after deconges-
tion normally congured. Mucosa normal.
• Measurement ndings: cf. Fig.27.13.
Analysis oftheRhinometric Findings
Extent ofObstruction
RRM resistance: Before decongestion: very slight
obstruction on the right and severe obstruction on
the left. After decongestion: on both sides no
obstruction.
2. Step: cause of obstruction
Mucosal
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Narrowing
RRM: resistance or hydraulic diameter difference
before and after decongestion
ARM: MCA2 or volume difference before and after decongestion
349
Skelettal
Path. NVC
Path. turbulence
Fig. 27.12 Schematic algorithm: procedure for diagnosing the extent and cause of nasal obstruction using RRM and
ARM
Table 27.9 Cottle area and corresponding anatomical
endonasal areas
Cottle
region Anatomical area in the nose
Region 1External nasal ostium (nostrils)
Region 2Isthmus nasi (nasal isthmus)
ARM: extent and localization of a narrowing
RRM: aerodynamic effect (d
RRM: extent and beginning of the
resistance increase caused by NVC
RRM: Transition of laminar to turbulent flow behavior
AR: In flow opening (MCA1) and shape (diffuser opening angle ϕ)
of the nasal diffusor
, R)
n
cal stenoses. MCA1 on the left slightly more
narrow. Because resistance is not increased,
this narrowing and the septal deviation have to
be assessed as physiological. The slightly
enlarged diffuser opening angle on the right
results in a pronounced, but not a pathological
turbulence.
Region 3Region beneath the cartilage and bony
pyramid, corresponding in terms of uid
dynamics to the nasal diffuser (see Chap. 20,
Sect. 20.3.1.3)
LRM: During light and moderate physical activ-
ity (heart rate 80–>100/min.) between
11:30a.m. and 8:30p.m. in concert type of
the nasal cycle. Later on up to 2:00a.m. with
decreasing activity classical type with
Cause oftheObstruction
RRM: The increase of width due to decongestion on
the left from a hydraulic diameter of 3.5mm to a
decreasing ow values up to complete resting
phases during sleep between 2:00 a.m. and
8:00a.m.
normal dimension of 5.9mm indicates a severe
congestion without skeletal stenosis. An increased
resistance due to inspiratory nasal valve collapse
or pathological turbulence is absent.
ARM: Normal curves with regard to both area
and distances with sufcient wide physiologi-
Assessment
Normal nasal breathing on both sides in the presence of a physiological deviation of the septum
towards the left. Congestion on the left is regarded
as resting phase of the nasal cycle.
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G. H. Mlynski et al.
Fig. 27.13 Rhinoresistometric measurements for clinical example 1
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351
27.3.2.2 Example 2: Severe Nasal
Obstruction ontheRight
DuetoaSeptal Deviation
Patient: male, 24years of age (same patient like
in Figs.27.5, 27.8 and 27.11)
• History: Trauma 2years ago.
• Complaints: Since the trauma, a severe nasal
obstruction on the right.
• Outer Nose: Normal.
• Endonasal ndings: Severe septal deviation
towards the right in Cottle’s regions 2 and 3.
Inferior turbinate enlarged on the left, after
decongestion normally congured. Mucosa
normal.
Rhinometric Findings: cf. Fig.27.14a
• Analysis of the preoperative rhinometric
ndings.
Extent ofObstruction
RRM: resistance: Before decongestion, severe
obstruction on the right side, no obstruction
on the left. After decongestion, severe obstruction on the right side and unphysiological low
resistance on the left side.
Cause oftheObstruction ontheRight
RRM: hydraulic diameter: The increase of the
width on the right side from a hydraulic diameter of 3.5 to 4.4mm by decongestion indicates
both, a swelling and a skeletal stenosis. The
increase of resistance due to inspiratory NVC
at 250mL/s is >100%. Besides, complete turbulence at 68 mL/s contributes to the severe
nasal obstruction. The left nasal side is with the
hydraulic diameter of 7.4mm too wide. This
causes a pathologically low resistance as well
as a borderline turbulence behaviour.
ARM: The Cottle regions 2 and 3 are after decon-
gestion on the right side very narrow and on
the left side too wide. The strong swelling on
the left side can be regarded as physiological
swelling to achieve a more narrow space for
allowing the creation of resting phases in a
nasal cavity, which has too wide skeletal
dimensions (“compensatory enlargement of
the turbinate by swelling”).
LRM: This examination was only performed for
scientic and illustrative reasons. Clinically, it
was not necessary for diagnosis.
During 24 h, no cyclic change of resting and
working phases can be observed. The right side does
not contribute to oxygen supply and the left nasal
side only to a very small amount. Nasal minute volume at 2–3 L/min indicates a permanent mouthbypass breathing. During rising physical activity no
increase of nasal minute volume is observed (RRM).
Assessment
The congestion on the right side is regarded as physiologic. After decongestion, on the right side a skeletal stenosis remains as cause for the sever
obstruction (septal deviation in Cottle regions 2 and
3). This results in an increased resistance due to a
constriction of nasal airow canal (see Sect. 20.2.1).
In addition, this stenosis causes a pathological inspiratory NVC via a Bernoulli phenomenon (see Sect.
20.2.3). Moreover, the constriction in the opening of
the diffuser causes pathologically increased turbulence (see Sect. 20.4). Both contribute to the severe
nasal obstruction. Stiffening of the nasal wing is not
indicated because the correction of the stenosis via a
septoplasty will normalize the width of the internal
ostium and therefore reduce the underlying pathological high negative pressure because of Bernoulli
phenomenon) (see Sect. 20.5). Consequently, pathological NVC will abolish. The narrow ostium internum is also the cause for the pathological turbulence
behaviour (see Sect. 20.4). Constant mouth-bypass
breathing is required as sufcient nasal minute volume cannot be achieved even with physical rest.
Rhinosurgical Planning
Septoplasty to correct the stenosis on the right
side. Thereby, two aims are achieved:
– On the right nasal side in Cottle areas 2 and 3
the stenosis will be enlarged, thus decreasing
both resistance and Bernoulli phenomenon.
Besides, the opening of the diffuser will be
expanded, reducing endonasal turbulence.
– On the left nasal side, cross-sectional area of
Cottle areas 2 and 3 will decrease and thereby
the pathologically low resistance corrected.
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G. H. Mlynski et al.
Fig. 27.14 Pre- (a) and 1 year postoperative (b) rhinoresistometric measurements for clinical example 2
nate is contraindicated [52, 53]. The too wide
cavum will get more narrow in Cottle area 3.
Consequently, endonasal congestion will
decrease postoperatively within a few days.
A turbinate reduction of the left inferior turbi-
Analysis ofPostoperative Rhinometric
Findings
RRM: The preoperatively increased resistance on
the right and too low resistance on the left has
normalized to a very slight obstruction
(0.20sPa/mL) on both sides. Besides, the severe
Rhinosurgery
Septoplasty without surgery of the turbinate.
One year postoperatively, the patient was
re-assessed
turbulence on the right and the borderline turbu-
lence on the left have normalized to a physio-
logical status. A normalization of NVC can be
observed in comparison to preoperatively.
ARM: The septum is within the midline in Cottle
• Complaints: No nasal obstruction on the right.
• Outer Nose: Normal.
• Endonasal ndings: Septum in the midline in
Cottle’s regions 2 and 3. Inferior turbinates after
decongestion normally congured. Mucosa
normal.
• Measurement ndings: see Fig.27.14b.
areas 2 and 3 and accordingly, both nasal cavities are sufciently wide.
LRM: A classical nasal cycle is observed with
the capability of compensation during rising physical activity, so that the heart rate
curve and the curve for the NMV have a
largely uniform course (see Sect. 20.5).
ab
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353
27.3.2.3 Example 3: Severe Nasal
Obstruction ontheLeft
DuetoSeptal Deviation
Patient: female, 19years of age
• History: Trauma at the age of 16years.
• Complaints: Severe nasal obstruction on the
left. Dry nasal mucosa with nasal crusts (Sicca
syndrome).
• Outer Nose: Normal.
• Endonasal ndings: Septal deviation
towards the left in Cottle’s region. Small
valve angle on the left > on the right.
Turbinate congestion on both sides (right >
left), after decongestion normally congured inferior turbinates. Dry mucosa on the
left > on the right.
• Measurement ndings: cf. Fig.27.15a.
• Preoperative analysis of rhinometric ndings.
Extent ofObstruction
RRM: Resistance: Before decongestion, severe
obstruction on both sides. After decongestion,
slight nasal obstruction on the right and severe
obstruction on the left.
Cause oftheObstruction ontheRight
RRM: Based on the increase of width by decon-
gestion from a hydraulic diameter of 3.2 to
5.9mm, a severe swelling is indicated but no
skeletal stenosis. No pathological inspiratory
NVC.Complete turbulence at 165mL/s after
decongestion contributes only in a moderate
amount to nasal obstruction.
ARM: After decongestion internal ostium right
(MCA1 0.61 mm) is only slightly greater
compared to the left (MCA1=0.59mm).
Cause oftheObstruction ontheLeft
RRM: Based on the increase of width by deconges-
tion from a hydraulic diameter of 4.6 to 4.9mm,
both a slight swelling and a severe skeletal stenosis is indicated. Moreover, pathological turbulence (complete turbulence at 72 mL/s)
contributes to nasal resistance and thereby to
nasal obstruction. No pathological inspiratory
NVC.
ARM: In the region of the septal deviation (Cottle
area 2) cross-sectional area after decongestion
of 0.59cm2 is only slightly smaller than the
non-obstructed contralateral side (0.61cm2).
LRM: not mandatory.
Assessment
The swelling on the right side causes the severe
obstruction. This congestion has to be regarded as
physiological state due to a resting phase at the
time of the measurement. After decongestion,
resistance remains slightly increased. On the left,
decongestion reveals a persisting skeletal stenosis
Fig. 27.15 Pre- (a) and 1 year postoperative (b) rhinoresistometric measurements for clinical example 3
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